Psychiatric Consultation in a Psychotropic Medication Oversight Program for Foster Children: The Ill...
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Psychiatric Consultation in a Psychotropic Medication Oversight Program for Foster Children: The Illinois Model. Michael W. Naylor, M.D. University of Illinois at Chicago Director, Clinical Services in Psychopharmacology. Background. Historical context

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Psychiatric Consultation in a Psychotropic Medication Oversight Program for Foster Children: The Illinois Model

Michael W. Naylor, M.D.

University of Illinois at Chicago

Director, Clinical Services in Psychopharmacology


Background

  • Historical context

    • DCFS challenged by federal courts, DOJ and ACLU

      • inadequate casework

      • chaotic and dangerous placements

      • substandard care

    • Illinois violating constitutional rights of children


Background

  • Historical context

    • ChicagoTribune 1995 editorial series:

      • DCFS called “the worst child welfare system in America…” and “a cruel, indifferent bureaucracy that harms kids.”

      • “system of shame”


Background

  • Historical context

    • Federal court-approved consent decree (B.H. v Suter, 1991)

      • DCFS and ACLU agree to collaborate on system reform plan


State Context

  • Psychotropic medication consent

    • DCFS Rule 325

    • Clinicians wishing to start a foster child on a psychotropic medication must obtain consent from the DCFS Guardian


State Context

  • DCFS Psychotropic Medication Consent Program

    • Two components:

      • Centralized Psychotropic Medication Consent Line

        • Office of the DCFS Guardian

      • Clinical Services in Psychopharmacology

        • University of Illinois at Chicago


State Context

  • Centralized Psychotropic Medication Consent Line

    • Office of the DCFS Guardian

      • legal guardian for children committed to the Department

      • responsible for providing consent for medical, surgical, and psychiatric treatment


State Context

  • Clinical Services in Psychopharmacology

    • provide independent review for all psychotropic medication requests

    • monitor utilization of psychotropic medications

    • provide consultation on particularly complicated cases


State Context

  • Clinical Services in Psychopharmacology

    • notify the Guardian where provider patterns warrant review

    • conduct training for DCFS, foster parents and childcare providers on psychotropic medications

    • disseminate information regarding new pharmaceutical developments and alerts


Consent Process


Psychotropic MedicationRequest Form

  • Demographic information

  • name

  • DCFS ID Number

  • date of birth

  • sex

  • race

  • weight and height

  • placement

  • physician’s name and specialty


Psychotropic MedicationRequest Form

  • Clinical information

    • diagnosis

    • current medications and dosage

    • symptoms/rationale

    • requested medication

      • dosage and frequency


Consultation

  • Three main providers of consultation for clinicians treating foster children:

    • Clinical Services in Psychopharmacology

    • DocAssist

    • Consult for Kids


Clinical Services in Psychopharmacology

  • Consultation

    • consent process

      • independent review of the appropriateness of the psychotropic medication consent request

      • recommend action to DCFS

        • approve

        • deny

        • modify


Clinical Services in Psychopharmacology

  • Consultation

    • oversight

      • formal

        • high risk prescribers

        • emergency medication utilization

      • informal

        • feedback from Administrative Case Reviews

        • concerns expressed by caseworkers, regional nurses, guardian ad litem, Court Appointed Special Advocates, judges, Office of the DCFS Guardian


Clinical Services in Psychopharmacology

  • Consultation

    • clinical

      • clinical concerns that arise in the course of the independent medication review

      • MD:MD

      • review of consent history

      • chart review

      • face-to-face


Clinical Services in Psychopharmacology

  • Consultation

    • prior authorization

      • provided consultation to HFS vis-à-vis prior authorization for antipsychotic medications and stimulants for children

      • DCFS consent for a medication serves as prior authorization for foster children


Clinical Services in Psychopharmacology

  • Consultation

    • systemic

      • consult on development of policies, best practice guidelines re: mental health care for foster children

      • co-write legislation


Clinical Services in Psychopharmacology

  • Consultation

    • monitoring/QI

      • medication utilization patterns

        • rate of copharmacy with two or more antipsychotics

        • rate of polypharmacy by age group

      • timeliness of consent process

      • compliance with Rule 325


Impact of Consultation


Consultation

  • Illinois DocAssist

    • established through the joint efforts of the Department of Healthcare and Family Services, the Department of Human Services – Mental Health, and the University of Illinois at Chicago

    • funding support by the Illinois Children’s Mental Health Partnership


Consultation

  • Illinois DocAssist

    • clinical

      • quality of treatment for Medicaid funded children with mental illness in the primary care setting

    • client – Medicaid funded providers with a focus on primary care

    • purpose – improve the identification, diagnosis and treatment of children and youth with mental health issues through consultation, education and referral services


Consultation

  • Consult for Kids Program

    • established by DCFS to provide primary care clinicians participating in HealthWorks with resources to evaluate foster children in their care for mental health and behavioral concerns


Consultation

  • Consult for Kids Program

    • clinical

      • address questions and concerns about a foster child’s emotional, interpersonal, behavioral or cognitive problems

    • client – primary care providers

    • purpose – help primary care providers navigate a challenging child through the child welfare system


Consultation

  • Challenges to effective consultation

    • “silo-ization”

      • duplication of services

      • lack of coordination

    • informing stakeholders of the services

    • meeting demand for services


Consultation

“The Curse of Unwelcome Oversight

and Unrequested Consultation.”


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